Clostridium difficile is a spore-forming gram positive anaerobic bacillus that is part of the normal faecal flora of about 3% of healthy adults. Colonization rates may be much higher than that in hospitalized patients and in newborns. It can occur at any age, but elderly adults and debilitated patients are most susceptible to disease. In such patients, even a short course of antibiotic therapy for prophylaxis or treatment of minor infections can lead to colonization and Clostridium difficile infection. The list of causative antimicrobials is extensive but, in general, any antimicrobial agent that can get into the intestinal lumen can, even in small amounts, induce disease.

Pulmonary rehabilitation is a multidisciplinary education and exercise programme of care for patients with chronic respiratory disease, particularly Chronic Obstructive Pulmonary Disease (COPD). It aims to reduce symptoms, decrease disability, increase participation in physical and social activities and improve overall quality of life in patients who may still be very disabled despite optimal pharmacological treatment. Pulmonary rehabilitation first began more than 30 years ago and is now established as an important part of the management of COPD.

Good communication between health and social care professionals and patients, their families and carers is recognized increasingly as integral to best management. Thus a central principle of the NHS Plan is that all patients should have open access to information about services, treatments and performance and should be treated as partners in their own care. Lack of information and poor communication is a common basis for complaints, and there is little evidence that older patients want any less information than those who are younger Certainly, if elderly people living with long-term illness, frailty or disability are fully informed, they will be better able to make appropriate decisions and actively participate in managing their own condition and their lives. In general, it is for professionals to provide the required information and support, or to direct people to other quality sources of evidence-based information, and not for them to decide whether or what should be disclosed.

Traditional clinical review articles, also known as updates, differ from systematic reviews and meta-analyses. Systematic reviews comprehensively examine the medical literature, seeking to identify and synthesize all relevant information to formulate the best approach to diagnosis or treatment. Meta-analyses, sometimes known as quantitative systematic reviews seek to answer a narrow clinical question, often about the specific treatment of a condition, using rigorous statistical analysis of pooled research studies. Updates review the medical literature almost as carefully as a systematic review but discuss the topic under question more broadly and make reasoned judgements where there is little hard evidence, based upon the expertise of the reviewer. It may not include evidence from foreign language journals or look for unpublished data on a topic, so will tend to be more applicable to the local situation than a systematic review, as it may take into account local shortages of equipment or personnel.

Nutrient inadequacies, especially in older persons, impact adversely on health, increasing the risk of acute and chronic disease and prolonging recovery from illness. Malnutrition is a condition due to an inadequate calorie and micronutrient intake that fails to meet the basic requirements for body maintenance, growth and development. Malnutrition often occurs in older people in acute hospital settings, among residents in nursing homes and in long-term care. Malnutrition in institutionalized older people is as high as 40–50%.

The connective tissues diseases are a group of related disorders, which are primarily autoimmune and triggered by environmental factors in susceptible individuals. They usually affect multiple organs and most of them can result in a shortened lifespan. Fortunately they are also very uncommon, and even rarer in later life. They are usually diagnosed on a clinical basis and, to help this, most have strict diagnostic criteria. However, a lot of patients do not fit well into one particular category, but overlap with several. Indeed a single individual could have features of or fulfil the criteria for all the diseases discussed in this review. A further group of patients are ‘undifferentiated’, often having mild disease and initially failing to fulfil any set of criteria.

Since the last review of this subject in this journal, there have been a number of developments in this area that are of relevance to the management of clinical problems of older people. It is important to note that the results of blood tests obtained in older people may differ in significance compared to those obtained from younger people. This review is based on a literature search using Medline, usually going back to 1998, combining sets of papers with the key word ‘elderly’. Studies known to the author were also included.

Over the last decades of the twentieth century survival after stroke has increased considerably, with the greatest effect being in patients over 75 years. As a result, stroke is now affecting tissues and organs previously regarded as being of little relevance. The skeleton is one body system that in the longer term is affected by stroke, with fracture now becoming a significant complication. Bone loss can now readily be measured, and therapies that may be able to prevent bone loss and fracture are available for clinical trial. This review examines the direct and indirect factors that influence the relationship between fracture and stroke.

Factors increasing the risk of urinary tract infections in old age include reduced T lymphocyte regulation, decreased B lymphocyte antibody synthesis, impaired killer T cell function and slowed neutrophil chemotaxis. More practical causes for a high incidence of urinary infections are multiple pathology and poor nutrition. In women, a low oestrogen level increases the intravaginal pH, resulting in the lactobacillus being replaced by a pathogenic agent. Faecal stasis may also increase the risk of a urinary infection. The presentation and severity of a urinary infection are affected by intercurrent disorders such as diabetes mellitus, poor bladder control, concurrent medication and cognitive impairment. Other relevant but less common disorders are bladder calculi and tumours. Common signs of pyouria in old age are urinary incontinence, anorexia, lethargy and confusion. The infection may even be asymptomatic and this is discussed later.

Joint problems in older people are common–both as ongoing chronic problems but also individuals presenting for the first time with joint symptoms. The assessment of an elderly person presenting with joint symptoms poses special challenges. There is a large potential differential diagnosis and more than one form of arthritis may co-exist, most commonly osteoarthritis. The clinical presentation in older patients may differ from typical findings in a younger individual and co-morbid conditions may complicate management strategies. In this article we discuss the differential diagnosis and management of conditions presenting as inflammatory arthritis in older people.

This review examines the relationship between unsteadiness, falling and anxiety, and their combined impact on the lives of older people. Over one in four people over 69 fall each year, and a higher proportion of those over 74. Although only one in ten incur serious injury as a direct result of the fall, fear of falling can often lead not only to psychological distress but also to restriction of activity and an unnecessary and undesirable loss of independence. Naturally, symptoms of unsteadiness constitute a key risk factor for falling. As many as one in three older people have suffered from unsteadiness and/or dizziness at some time. Like falling, dizziness and unsteadiness are also associated with distress and restriction of activity.

Over the last few decades, the prevalence of chronic renal impairment has increased throughout the population, especially in the older age group. This is not just a consequence of the general increase in longevity, but is also caused by a higher incidence related to improved survival of patients with chronic diseases affecting renal function, such as diabetes, hypertension and ischaemic heart disease, and improved survival of patients with established renal failure.

The kidneys undergo a multitude of structural and functional changes with advancing age. Structurally, there is a progressive loss of predominantly cortical renal mass, a decrease in the number of glomeruli, an increase in the proportion of sclerotic glomeruli, atherosclerotic vascular changes and interstitial changes resulting in atrophy and fibrosis. Functionally, there is a decline in the glomerular filtration rate (GFR), resulting primarily from a decrease in the number of functioning nephrons.

Orthostatic hypotension (OH) is a clinical condition which frequently results in troublesome symptoms such as dizziness, giddiness, blurred vision and light-headedness. It is a common disorder associated with an increased risk of falling, especially in older individuals. OH is the presenting haemodynamic manifestation of several different and diverse underlying pathological conditions, including disorders of blood pressure (BP) regulation and disorders leading to reduced intravascular volume.

Polymyalgia rheumatica and temporal arteritis represent opposite poles of a single disease spectrum. In the former, girdle stiffness predominates; in the latter, frank vasculitis is demonstrable. There is no diagnostic laboratory test for polymyalgia rheumatica, and earlier reviews in 1993 and 1998 in this journal both drew attention to the difficulty in diagnosing polymyalgia rheumatica, particularly in the elderly.

As the number of people living to reach old age increases, so the proportion of cancers presenting in this age group increases to an even greater degree. Although 70% of all cancers in men and women occur over the age of 65 and in the over-75s, who are perhaps more appropriately classified as ‘elderly’, the figures are still very high (46% of all cancers occur in women over 75 and 35% in men over 75). As a consequence, cancer is rapidly becoming a problem of late life, and the management of patients in old age is an important part of general oncology. The magnitude of the overlap between old age and cancer is increasing because of improved life expectancy, more sensitive methods of diagnosing cancer and the biological fact that most cancers occur more commonly with increasing age. It is interesting, however, to put these figures into a more general context by examining the different causes of death in older patients by decade.

The term person-centred care has become all-pervasive on the UK dementia care scene. It has been suggested that it has become synonymous with good quality care. It seems that any new approach in dementia care has to claim to be pc (person-centred) in order to be P.C. (politically correct). The term is used frequently in the aims and objectives for dementia care services and provision in the UK and the US, although what lies behind the rhetoric in terms of practice may be questionable.

Acute stroke is a commonly-used term in clinical practice and in standard texts, but tends to reinforce a widely-held perception of stroke as a short-term condition. Arguably, this brief, time-limited approach to stroke care has become more dominant, with the reliable evidence that hospital-based stroke care, using the model of a stroke rehabilitation unit, confers improved patient outcomes. For patients disabled by stroke, however, the substrate for longer-term problems is obvious, and stroke as a chronic condition is a more helpful and user-centred health care paradigm.

Medical advances and improved living conditions mean that people who have an intellectual disability (ID), characterized by lifelong limited intellectual, social and vocational capabilities, are living longer. There has been a concomitant increase in the prevalence of age-associated diseases, including dementia.

Loneliness may be regarded as a ‘geriatric giant’, leading to impaired quality of life, greater need for institutional care and increased mortality. For the past 30 years, a growing number of studies have focused on loneliness. However, the majority of these have been descriptive and cross-sectional. Further longitudinal studies are needed to understand the causal relationship between life-events and loneliness, its prognostic significance and, in particular, whether negative consequences may be alleviated.